Author Archives: gutsandgrowth

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About gutsandgrowth

I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information. Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources. I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract. During my fellowship, I had the opportunity to work with some of the most amazing pediatric gastroenterologists and mentors. Some of these individuals included Mitchell Cohen, William Balistreri, James Heubi, Jorge Bezerra, Colin Rudolph, John Bucuvalas, and Michael Farrell. I am grateful for their teaching and their friendship. During my training with their help, I received a nationwide award for the best research by a GI fellow. I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. In addition, I have been recognized by Atlanta Magazine as a "Top Doctor" in my field multiple times. Currently, I am the vice chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN), American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation. As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids), I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, hepatitis C, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources. I am fortunate to work at GI Care For Kids. Our group has 17 terrific physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. Our group of physicians have worked closely together for many years. None of the physicians in our group have ever left to join other groups. I have also worked with the same nurse (Bernadette) since I moved to Atlanta in 1997. For many families, more practical matters about our office include the following: – 14 office/satellite locations – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support for abdominal pain and feeding disorders – participation in ImproveCareNow to better the outcomes for children with inflammatory bowel disease – office endoscopy suite (lower costs and easier scheduling) – office infusion center (lower costs and easier for families) – easy access to nursing advice (each physician has at least one nurse) I am married and have two sons (both adults). I like to read, walk/hike, bike, swim, and play tennis with my free time. I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have helped enroll patients in industry-sponsored research studies.

“March of Science”

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A fascinating commentary (“The March of Science –The True Story”  L Rosenbaum NEJM 2017;377: 188-91) discuss issues regarding mistrust of science in this age of ‘alternative facts.”

Here are some key points:

  • “Nutrition science may be the area that provides the most ammunition for distrust, given the combination of uncertainty, public interest, and powerful preferences. Indeed, skepticism of most nutrition science is warranted, given the often insurmountable challenges of controlled, blinded experimentation…The confluence of these factors..often invoked to condemn the scientific process more generally: Why should I believe you people when you people are always changing your minds?”
  • “Remarkable gains in human longevity are just one manifestation of science’s success–but….’No one wants to hear about the plane that lands.'”
  • There has been a shift “in the tone of public discussions of science.” Instead of someone being “wrong,” they are now “corrupt” or “evil.”
  • Due to potential for condemnation, there is fear of “venturing into the fray” which “means that the public hears far more from science’s critics than its champions. This imbalance contributes to “science is broken” narratives ranging from claims about the pervasiveness of medical error to the insistence that benefits of our treatments are always overhyped.
  • Changing the narrative: “we have to learn to tell stories that emphasize that what makes science right is the enduring capacity to admit we are wrong. Such is the slow, imperfect march of science.”

My take: Widespread skepticism and confirmation bias have the potential to disrupt highly effective medical treatments by confusing them for those that are unproven.

Related blog posts:

Dupont Forest, NC

 

Predicting Future Liver Disease with GGT Levels in Biliary Atresia Patients

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A recent study (AJ Freeman, VL Ng, S Harpavat, A Hrycko, Z Apted, P Bulut, T Leong, SJ Karpen. Clin Gastroenterol Hepatol 2017; 15: 1133-35) describes the predictive value of γ-glutamyltransferase (GGT) in predicting thrombocytopenia/portal hypertension among biliary atresia patients.

In this retrospective study from three centers who had followup for at least 4 years, GGT values at 2 years of age were examined among biliary atresia patients (n=46) who continued with their native liver.

Key findings:

  • GGT ≥100 U/L had a predictive positive relationship with thrombocytopenia at 4, 5, and 6 years of age.  Patients with elevated GGT had lower platelet count (160 vs. 211) and their values continued to decline. GGT ≥100 U/L at 2 yrs predicted thrombocytopenia (<150) at age 4 with a sensitivity of 0.88, specificity of 0.57.
  • Patients with normal GGT values had “essentially stable platelet counts over the next 4 years.” GGT <100 U/L at 2 yrs predicted a low risk of thrombocytopenia with negative predictive value of 0.89, 0.92, and 0.93 at age 4, 5, and 6 respectively.

My take: This study quantitates a useful point –patients with biliary atresia and elevated GGT values are likely to develop evidence of portal hypertension.

Brevard, NC

Hazardous Toys: Jarts and Magnets

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I had completely forgotten about Jarts until reading a recent editorial by Athos Bousvaros (J Pediatr 2017; 186: 6-7). He succinctly describes how these lawn darts were ultimately removed from the market primarily due to the advocacy of a father who became a strong advocate after the death of his daughter.

A more complete description of the effort to remove Jarts -from Mental Floss website: How One Grieving Father Got Lawn Darts Banned

Dr. Bousvaros, in commentary on a study on high-powered (neodymium) magnets (Rosenfeld D et al. J Pediatr 2017; 186: 78-81) describes the similarities between these magnets and the jarts.  Both have caused catastrophic injuries and death.  However, the recent removal of these magnets from the market was overturned.  There is no national tracking system for magnet ingestions in U.S. or Canada.  However, the referenced study demonstrated a dramatic reduction  in medical/surgical procedures in 2014-2015 (n=10) when a ban was placed compared to 2011-2012 (n=29).

For U.S physicians, all we can do currently is to report to the CPSC (Consumer Product Safety Commission) all magnet-related injuries and to publicize the dangers of these hazardous products.  To report: go to CPSC website (link: CPSC website) and “report an unsafe product” on the right side of the page.

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Big Study of Primary Sclerosing Cholangitis

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This blog has reviewed multiple publications on primary sclerosing cholangitis (see blog posts below). Now, a study from 37 centers with 7121 patients with PSC has been published: TJ Weismuller et al. Gastroenterol 2017; 152: 1975-84. Given the relative infrequency of PSC, this retrospective report offers more insight into the predictors of the clinical course of PSC.

Key points:

  • Most of the patients in the study had large duct PSC (89.8%); 3.6% had small duct disease and 6.6% had overlapping PSC/autoimmune hepatitis.
  • Mean age of cohort at diagnosis was 38.5 yrs.
  • 70% of PSC patients developed IBD with ulcerative colitis (UC) about 5-times more common than Crohn’s disease.
  • 37% of patients met the primary endpoint of either liver transplantation or death
  • Individuals with small duct PSC had a favorable outcome; only one of 254 (0.4%) developed cholangiocarcinoma (CCA). Risk of primary endpoint was much lower in small duct PSC compared with classical PSC with an adjusted hazard ratio of 0.23.
  • Individuals with PSC/AIH variant also had a reduced risk of primary endpoint compared with classical PSC with an adjusted hazard ratio of 0.73.
  • Overall, CCA occurred in 594 patients (8.3%); the incidence of CCA changed markedly with the age of the patient.  In the youngest group (<20 years), the rate was 1.2 per 100 patient-years, it was 6.0 in 21-30 yr-olds, 9.0 for 31-40 yr-olds, 14.0 fr 41-50 year olds, 15.2 for 51-60 yr-olds, and 21.0 per 100 patient-years in those older than 60 years.
  • The absence of IBD, particularly UC, was associated with a lower risk PSC clinical course. Patients with UC had increased liver disease progression compared with patient’s with Crohn’s disease, with a HR of 1.56.
  • The median transplant-free survival time was 14.5 years; the estimated survival was approximately 21 years in the entire cohort

It is noted that an important limitation is that the cohort is from specialist centers and may not reflect a more typical population-based cohort; that is, this patient population is likely to be severely affected.

My take: Patients with small-duct PSC have a much lower risk of disease progression.

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Piedmont Park Arts Festival

Is there a link between Eosinophilic Esophagitis and Celiac Disease?

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Probably most pediatric gastroenterologists have seen patients who underwent endoscopy for celiac disease and found out that the patient had both celiac disease and esophageal eosinophilia.  Whether the esophageal eosinophilia should be classified as eosinophilic esophagitis (EoE) is based in part on whether one concludes that the EoE is a separate disorder and unrelated to the celiac disease.

One useful retrospective study on this topic (S Hommeida et al. JPGN 2017; 65: 58-63) examines the association between celiac disease and EoE.   Key findings:

  • Among a cohort of 10,201 children seen at the Mayo clinic, 595 were considered to have EoE and 546 had celiac disease.
  • Only 10 patients had both celiac disease and EoE.
  • The risk of EoE was not increased in children with celiac disease compared to those without celiac disease (odds ratio 0.29).  The prevalence of EoE in children with celiac disease was 1.8% whereas the prevalence among all children undergoing endoscopy was 5.8%.
  • 4 of 10 children treated only with GFD clinically improved (no followup histology)

Limitations:

  • The diagnosis of EoE was not clear in this study.  As noted in the associated editorial (pg 1-2), “the use of a high-dose proton pump inhibitor at the time of initial diagnosis is not mentioned.”
  • Overall, the number of patients with both EoE and celiac disease was small.  Thus, a much larger study could be necessary to prove the lack of an association.

My take: This study suggests that there is not an association between EoE and celiac disease. Some patients with both disorders will respond to a gluten free diet, whereas some will require additional treatment directed at EoE.

Related study: T Wallach et al. JPGN 2017; 65: 64-8. This retrospective study showed poor adherence to biopsy guidelines in EoE and celiac disease.  Among 9171 children, 8% were biopsied in accordance with 2007 AGA EoE consensus recommendations and 35% in accordance with  2006 AGA celiac guidelines.  Higher detection rates were observed among patients who had higher adherence to diagnostic guidelines. With both diseases, obtaining sufficient number of biopsies is key; and with celiac disease, obtaining biopsies from duodenal bulb as well as distal duodenum is recommended.

Chattahoochee River, Sandy Springs

AGA Blog: What are the complications of PPI Therapy?

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AGA Journals Blog: What are the complications of proton pump inhibitor (PPI) Therapy?

The blog post reviews a recent article on PPIs and potential complications.

An excerpt:

A review article from Michael F. Vaezi et al discusses potential adverse consequences of proton-pump inhibitor (PPI) therapy in the July issue of Gastroenterology…(2017; 153: 35-48). The authors discuss overzealous conclusions based on weak associations that have caused widespread alarm, leading to inappropriate discontinuation of a medicine that is needed for an established disease process. They present absolute and relative risks for adverse effects associated with long-term use of PPIs…

Vaezi et al review the consistency of proposed associations with PPI use and the time period between the PPI exposure and outcome, and the effects of different doses. They provide guidance for methodologies of future studies.

The review article concludes that PPIs have revolutionized the management of patients with GERD and patients at risk of upper gastrointestinal ulceration and bleeding from aspirin or NSAIDs. However, many patients receive PPIs unnecessarily for conditions or symptoms for which they would not have been expected to provide benefit… Vaezi et al state that, as always, PPIs should be given in the lowest effective dose, for the shortest possible time.

They add that much of the evidence linking PPI use to serious long-term adverse consequences is weak and insubstantial. It should not deter prescribers from using appropriate doses of PPIs for appropriate indications.

Full text of original article: Complications of Proton Pump Inhibitor Therapy

Table 6 lists the strengths of the findings along with other Hill Criteria to assess all of the proposed complications.  The vast majority of potential complications have “weak” proof; the exceptions include bacterieal enteric infections/Clostridium difficile infection which have moderate strength of evidence and and fundic gland polyps which have high strength of evidence.

My take: This study and the associated AGA Journals blog post indicate that most of the reports of complications associated with PPI remain unproven and are based on weak evidence.

 

Briefly Noted: Outpatient Liver Biopsy

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A small retrospective study (R Bolia et al. JPGN 2017; 65: 86-88) with 497 patients (626 biopsies) found that all complications were identified within 8 hours.  Thirty (48%) had complications, with a subcapsular hematoma being most common (n=14).  Less common adverse events included fever (n=5), skin site ooze (n=3), intraperitoneal bleeding (n=3), hemobilia (n=2), anaphylaxis to gelfoam (n=2), and sepsis (n=1). In this study, the majority of biopsies were performed by interventional radiology (n=492); though, the complication rate was similar in both groups.

The authors conclude that their data support the outpatient liver biopsies in children.

My take: I disagree with the authors’ conclusion to some extent.  Their population is too small to detect rare but severe complications.  Our empiric practice is watch children older than 6 years of age for 6 hours and watch younger children (or others deemed at increased risk) for 24 hours.

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Prague